1. Bipolar Disorders

2. Lithium: works in 40-50% of patients
Treats mania, hypomania, and prevents recurrences
May tx depression in bipolar clients
Least effective for rapid cyclers and mixed episodes
Lots of side effects: gastrointestinal, weight gain, hair loss, acne, tremor, sedation, decreased cognition, incoordination
Long term effects on kidneys, and thyroid
Narrow therapeutic window-plasma level monitoring

3. Anticonvulsants Like seizures kindle seizures, mania kindles mania
Treats manic phase
Mechanism of action poorly understood, but believed to enhance GABA (inhibitory NT) and reduce glutamate (excitatory NT) and perform several other functions that are poorly understood at this time.

4. Valproic Acid- Depakote
First line tx for bipolar, especially for rapid cycling or mixed episodes
Plasma levels to ensure therapeutic range
Side effects: hair loss, weight gain, sedation, effects on developing fetus, menstrual disturbances, polycystic ovaries, hyperandrogenism, obesity, and insulin resistence

5. Carbamazepine/Tegretol
Less documented effects
Not FDA approved for mania
Side effects include sedation and hematological abnormalities

6. Lamotrigine/Lamictal
Not approved for bipolar
Evidence is showing it may be effective with manic, mixed AND depressive episodes in bipolar

7. Topiramate/Topamax Not yet approved for bipolar
Only anticonvulsant that has side effect of weight loss instead of weight gain

8. Other mood stabilizing drugs
Benzodiazepines: have anticonvulsant actions and are sedating. Used as adjunct therapies for agitation and psychotic behavior during mania
Antipsychotics: for Manic/depressive agitation and psychosis as adjunctive therapy. Atypical (newer) antipsychotics are being used for the management of mania. May become first line tx, especially for rapid cyclers or mixed episodes-in clinical trials.

9. Treatment Resistant patients: Depression
Augmenting agents: lithium, thyroid hormone, and BuSpar
Thyroid problems are commonly associated with depression especially in women. Adding thyroid to cls not responding to antidepressant (even without hypothyroidism) can increase efficacy
Also with bipolar cls resistant to mood stabilizers and rapid cyclers

10. Estrogen has few clinical studies as adjunct, but has important implications
Temazepam, vistiril, benadryl: medications for sleep/anxiety

11. Treatment resistant Bipolar
                                                      
Combination tx with two or more psychotropics is the rule rather than the exception for bipolar disorders
First line: lithium or Depakote
Second line: Atypical antipsychotics (sometimes first line)
Third line: combine the above two
Fourth line: Add benzo or traditional antipsychotic (restricted to acute phase)

12. Treating Bipolar with antidepressants
Antidepressants frequently decompensate a bipolar client, causing hypomania/mania and rapid/mixed cycling which are much more difficult to tx
If used, used sparingly and combined with mood stabilizers or other meds discussed

13. If the patient is not responding
Check for A&D, OTC,or other prescription use
Check hx with meds. Cls often say “I tried that” meaning they took it for 3 days to a week” Need 4-8 weeks for effects. If side effects caused discontinuation, consider augmenting with medication that curbs side effects.
Check for misdiagnosis: Cl dx is unipolar, but is actually bipolar. For example, is the cl with unipolar depression and drug induced agitation actually bipolar with drug induced rapid or mixed cycling? Another Anti depressant may worsen the condition even more. Try mood stabilizer or atypical antipsychotic.

14. Combining meds
Combinations should focus on combining the mechanisms of each drug, not just drugs
Use principles of synergy: 1+1=3, or 4 or 20
For depression, think NE and 5HT if not responding
For fatigue, apathy and cognitive slowing think NE (reboxitine not in US, but desipramine/Norpramine and other TCAs are as is Welbutrin) Think about side effects and combinations in making best choices.

15. Remember You can treat to Response or Remission…we want Remission
Prevention is very important due to Kindling, educate your clients
Reread information on how different personality types respond to medications so you can normalize and help cl stay compliant with meds

16. Know the signs of a manic, hypomanic or depressive episode for your clients. Cls will stop meds and not tell you because they want to please you.
Cls with hypomania and mania will often enjoy this aspect of their disorder. Educate on kindling. Have contact numbers for friends, family, etc. that will need to intervene.
Hypomania is often left without tx. Controversy on whether this will increase mania exists.